Gheorghe Liana, Iacob Răzvan, Vădan Roxana, Iacob Speranţa, Gheorghe Cristian
Department of Hepatology, Center of Gastroenterology and Hepatology, Fundeni Clinical Institute, 72437 Bucharest, Romania.
Rom J Gastroenterol. 2005 Sep;14(3):231-8.
Protein-calorie malnutrition (PCM) occurs in 20-60% of patients with hepatic cirrhosis and is associated with the development of life-threatening complications. We evaluated the effect of a modified, casein-vegetable-based, high-protein high-calorie (HPHC) diet on the outcome of cirrhotic patients with hepatic encephalopathy (HE).
One hundred and fifty three consecutive cirrhotic patients with overt HE were included in this study. An HPHC diet based on better-tolerated vegetable and milk-derived proteins was initiated in order to ensure the adequate protein-energy requirements of 30 kcal/kg/day and 1.2g proteins/kg/day. Serial (daily) assessments were done, including mental status, asterixis, a conventional Number Connection Test (NCT), bowel movements and blood ammonia level. The assessment of the mental status was performed using the West Haven scale. Favorable evolution or response to HPHC diet was defined as an improvement in HE stage with 1 or more (Delta > or =1 stage) after 14 days of diet.
During the HPHC diet, 122 patients (79.7%) improved in terms of response definition. A significant decrease in blood ammonia level was observed after 14 days (p<0.0001) in all patients, whatever the improvement of the mental status. A significant improvement in the NCT scores was also noted (p<0.0001). More patients with advanced HE (West Haven stage 3) precipitated by various factors showed a Delta = -2 improvement of their mental status during the modified HPHC diet compared with patients in lower initial stages (50% vs 18.9%, p=0.002). More patients in Child-Pugh B class had a Delta = -2 decrease in the grade of HE compared with patients in Child-Pugh C class (61.7% vs. 14%, p=0.001).
Almost 80% of patients in our study improved their mental status during the casein-vegetable-based HPHC diet, showing that dietary protein restriction is not required for the improvement of HE. A higher rate of improvement was noted in patients with severe impairment of mental status related to precipitating factors and in patients with well preserved liver function. The daily eating pattern consisting of 4 snack-meals and a late evening meal may contribute to HE improvement by equal protein distribution during the day.
蛋白质 - 热量营养不良（PCM）在20% - 60%的肝硬化患者中出现，并与危及生命的并发症的发生相关。我们评估了一种改良的、以酪蛋白 - 蔬菜为基础的高蛋白高热量（HPHC）饮食对肝硬化合并肝性脑病（HE）患者预后的影响。
本研究纳入了153例连续性显性HE肝硬化患者。开始采用基于耐受性较好的蔬菜和牛奶衍生蛋白的HPHC饮食，以确保满足30kcal/kg/天的能量需求和1.2g蛋白质/kg/天的蛋白质需求。进行了系列（每日）评估，包括精神状态、扑翼样震颤、传统数字连接试验（NCT）、排便情况和血氨水平。使用韦斯特黑文量表进行精神状态评估。对HPHC饮食的良好进展或反应定义为饮食14天后HE分期改善1期或更多（Δ≥1期）。
在HPHC饮食期间，122例患者（79.7%）在反应定义方面有所改善。无论精神状态是否改善，所有患者在14天后血氨水平均显著下降（p<0.0001）。NCT评分也有显著改善（p<0.0001）。与初始阶段较低的患者相比，更多因各种因素诱发的晚期HE（韦斯特黑文3期）患者在改良HPHC饮食期间精神状态有Δ = -2的改善（50%对18.9%，p = 0.002）。与Child - Pugh C级患者相比，更多Child - Pugh B级患者的HE分级有Δ = -2的下降（61.7%对14%，p = 0.001）。
在我们的研究中，近80%的患者在以酪蛋白 - 蔬菜为基础的HPHC饮食期间精神状态得到改善，表明改善HE不需要限制饮食蛋白质。与诱发因素相关的精神状态严重受损的患者以及肝功能保存良好的患者改善率更高。由4次加餐和一顿晚餐组成的每日饮食模式可能通过白天蛋白质均匀分布有助于改善HE。
